orthopaedics

1. PRESENTED BY-Dr. AKASH KUMAR

2. Nerve is defined as a bundle of fibre that use electrical
and chemical signal to transmit sensory and motor
information from one body part to another.
Peripheral nerves are made up of
1. Axon
2. Connective tissue- endoneurium
perineurium
epineurium
STRUCTURE OF PERIPHERAL NERVE

3. Structure of a Nerve
• Endoneurium surrounds
each fiber
• Groups of fibers are bound
into fascicles by the
perineurium
• Fascicles are bound together
by epineurium

5.  Entire nerve is supplied through the
mesoneurium
 Blood supply is :-
Intrinsic ( longitudnal)
Extrinsic ( segmental)

6.  Primary/ Traumatic / Retrograde
degeneration:-
- Reaction proximal to the point of detachment.
 Secondary/ Wallerian/ Orthograde
degeneration:-
- Occurs distal to the point of injury.

7.  If endoneural tube with its contained schwann
cells is intact, then sprout may readily pass
along their former course & after regeneration
the schwann cell innervates their previous end
again.
 Growth rate: 1 mm/day or 1 inch/month
 Motor March: Muscle nearest to the site of
injury recovers first, followed by others as the
nerve reinnervates muscles from proximal to
distal.

9.  If endoneurial tube is interrupted, then
aimless migration of axonal sprouts occurs
throughout the damaged area into the
epineural , perineural or adjacent tissue
 End neuroma- wide separation of proximal &
distal stump
 Side neuroma- partial nerve cut
 Neuroma in continuity

10.  TRACTION
 CONTUSION
 COMPRESSION
 LACERATION
DETERMINES TYPE, MANAGEMENT
& PROGNOSIS OF NERVE INJURY

11. CLASSIFICATION

13.  MOTOR - PALPATE MUSCLE BELLY
 SENSORY - AUTONOMOUS ZONE
 SUDOMOTOR - LOSS OF SWEATING
 POSTURE / REFLEX
 FUNCTIONAL
 TINEL’S SIGN

14.  All muscles supplied by branches of nerve distal
to that level are paralyzed and become atonic.
 EMG changes are not seen - 8-14 days
 Spontaneous fibrillation – 3 weeks (onset of
atrophic changes within muscle fiber)
 Striations and end plate configurations are
retained for up to 12 months .
 Complete disruption and replacement of muscle
fibre - 3 years.

15.  Sensory loss follows – definite anatomical pattern
 Overlapping from adjacent nerves – confusing
 Autonomous zone- isolated zone of supply of
particular nerve
 Intermediate zone- larger area corresponds more
closely to the anatomical distribution of nerve
 Maximal zone – when a nerve is intact & adjacent
nerves are blocked, area of sensibility exceeds the
anatomical distribution of nerve

16.  Perception of pin prick – first recovers
 Pain fibers - small diameters- faster
regeneration
 Touch fibers – larger diameter - slow
regeneration

17.  RECOGNITION OF NERVE INJURY
 DETECTION OF RECOVERY &
MONITORING ITS PROGRESS

18.  ELECTRICAL STIMULATION
Faradic & Galvanic stimulation
 STRENGTH DURATION CURVES
 E.M.G.
 NERVE CONDUCTION VELOCITY

19. ELECTROMYOGRAPHY
Electromyography is the technique of recording the electrical
activity within the striated muscle belly via inserting a needle
in it.
The electrical signal generated by a muscle tissue detected
via electrode which is further amplified and monitored by
oscilloscope or a speaker or recorded in system
Alteration in signal is seen as various neuromuscular diseases
There are 2 common ways to perform EMG via using 3 small
monopolar needle electrode or by coaxial or concentric
electrode

22.  A graph plotting the intensity of electrical stimulus to
the length of time it must flow to produce response
 The curve is defined by rheobase and chronaxie
 Rheobase-is minimal amount of stimulus strength that
will produce a response.it is used to measure membrane
excitability
 Chronaxie-it is the stimulus duration that yields the
response and stimulus is exactly 2x of rheobase.

23. Right shift of curve showing poorer excitability
Upward kink in strength duration curve indicate partial
denervation

27. LESIONS OF
RADIAL NERVE
1. Very high lesion (in
the axilla)
2. High lesion (humeral
shaft level)
3. Low lesion(around
the elbow )
4. CHEIRALGIA
PARESTHETICA (at
the wrist)

28. Supinator muscle
examination
Test of
brachioradialis
Examination of
extensors of wrist and
fingers
Wrist
drop

29. VERY HIGH LESION (IN THE AXILLA)
1.Weakness of wrist, fingers and thumb extension –
wrist,fingers and thumb drop
2.Weakness of elbow extension – due to paralysis of the
triceps
3. Absent of triceps reflex
4. Sensory loss in the distribution of the more proximal
cutaneous branches

30. 1. Wrist drop / weakness of wrist extension – due to
paralysis of the Extensor Carpi Radialis Longus and Brevis
2. Finger drop / weakness of fingers extension at the MCPJ
– due to paralysis of the Extensor Digitorum
3. Thumb drop / weakness of the whole thumb extension –
due to paralysis of the Extensor Pollicis longus and brevis
HIGH LESION (HUMERAL SHAFT)
CLINICAL FEATURES

31. LOW LESION (AROUND THE ELBOW)
CAUSES
The posterior interosseous branch of the radial nerve is injured in :
Dislocation of the head of radius
Accidently injured during surgical excision of the head of the
radius
LOW LESION (AROUND THE ELBOW)
CLINICAL FEATURES
The wrist extension is preserved No wrist drop because branch
to ECRL arise proximal to the elbow. Weakness of the fingers
and thumb extension at the MCPJ No sensory loss

34. 1. INJUY ABOVE ELBOW (HIGH ULNAR LESION)
MOTOR AFFECTION
1. Paralysis of all muscles supplied (1 muscle in forearm , 15 muscles in hand)
2. Weak flexion of the wrist, with radial deviation of the hand (FCU)
3. Inability to flex the DIP of the medial 2 fingers (medial ½ FDP)
4. Inability to put the hand in the writing position (interossei & medial 2 lumbricals)
5. Loss of adduction of the thumb (adductor pollicis)
Partial Claw Hand DEFORMITY
Flat hypothenar eminence
SENSORY LOSS palmar & dorsal surfaces of medial 1½ fingers.

35. 2. INJURY AT OR ABOVE THE WRIST (LOW ULNAR LESION)
Motor: Limited to hand muscles only.
Sensory Loss: Loss of sensation from the palmar surfaces of the
medial 1 fingers only – because the palmar & dorsal cutaneous
branches are intact.

36. Ulnar paradox
• Hand is not markedly deformed because the ulnar half of flexor digitorum
profundus is paralysed and the fingers are therefore less clawed

37. SENSORY
DISTRIBU
TION
 C-Distal to the elbow
B/w 2 heads of FCU
 D-At the level of
medial epicondyle
 E-In the brachial
plexus
A-ulnar tunnel
syndrome,where the nerve
passes between pisiform &
hook of hamete
B-At wrist specially from
laceration, occupaional
trauma & ganglion

38. A-Involuntary abduction of
little finger
B-Hypothenar muscle wasting
C-ulceration of skin
Wasting of interosseus muscles

39. Card test for
interosseous
Abductor digiti minimi
Froment book test-adductor policis
Palpation of ulnar
nerve lateral to FCU
tendon
Egawa test-Testing the
dorsal interosseous muscle

40.  Paralysis of ulnar nerve and claw-finger
deformity

43. HIGH MEDIAN NERVE LESION
1. Wasting of muscles of forearm
2. Wasting of thenar eminence
3. Weakness of thumb abduction and opposition (APB + FPB)
4. Pointing Index (FDP, FDS, FPL)
5. Lost sensation at radial 3 1/2 digits
6. Weak Ok sign
7. Ape hand deformity

44. LOW MEDIAN NERVE LESION
I. Wasting of thenar muscle
II. forearm muscle spared
III. Paralyzed muscle of the hand
IV. Weakness of thumb abduction and opposition
V. Loss of abductor pollicis brevis + flexor pollicis brevis
VI. Lost sensation at radial three and half digits

45. Benediction attitude
Ape thumb deformity
FcrlPL
CARPAL TUNNEL SYNDROME

46.  Pronator teres
 Abductor pollicis brevis
 Loss of power indicates
a lesion above the wrist.
AIN-FPL

47. Muscle examined
Flexor pollicis longus- this muscle is tested by holding thumb at its base and
patient asked to bend terminal phalanx
Flexor digitorum superficialis and profundus –Oschner’s clasping test is when the
patient is asked to clasp the hand the index finger of the affected side fails to flex
remains to pointing index

48. Opponens pollicis

50. •Loss of sensation over the
‘regimental badge’ area
•Flattening of the shoulder
•Deltoid muscle contraction

51. NERVE
OF
LOWER
LIMB

54. Decreased sensation and numbness on the outer half of the leg or
dorsum of the foot.
Weakness of the ankle or foot
Foot drop
Toe drag while walking
High stepping gait
SIGNS AND SYMPTOMS

57. Sensation changes in the bottom of the foot and toes, including
burning sensation, numbness, tingling, or other abnormal
sensation, or pain.
Weakness of foot muscles.
Weakness of the toes or ankle.
Ankle that rolls outwards.
Muscle atrophy
SIGNS AND SYMPTOMS

58. TREATMENT OF NERVE INJURY
CONSERVATIVE
-In closed injury
-Aim-preservation of maximal range of motion and prevention of
contractures
-NSAIDS to relief pain
-Resting from any activities that cause the symptoms to get
worse.
-Applying ice to the sore area (due to sensory loss)
-A stretched muscle will become fibrotic so to keep the
paralyzed muscle in relax position and to prevent joint
contractures different splints are used.

59. Splints for nerve palsy
-Cock up splint
-Knuckle bender splint
-Opposition splint and thumb index finger web space splint
-Aeroplane splint
-Foot drop splint

61. SURGICAL INTERVENTION
-In open wound(except penetrating wounds) in which nerve has been
ijured , direct inspection at the time of irrigation and debridement is
indicated.
-When a sharp injury has obviously divided a nerve.
-When abrading, avulsing or blasting wounds has rendered
condition of a nerve unknown.
-Blunt or closed trauma with no clinical or electrical evidence of
regeneration after an appropriate time(3-4month).
-Nerve is intact before closed reduction but significant deficit is
found immediately after.

62. NERVE REPAIR
Primary repair(within hours)-An acute primary repair may be
undertaken if the wound is clean, the mechanism of injury is a sharp
laceration, the patient's condition is stable, and the surgical team and
its facilities are available
Delayed primary repair(within 8-15days)-If constellation of primary
repair circumstances is not encountered, perform a delayed primary
repair within 8 to 15 days. If repair is to be delayed, the nerve ends
can be tagged with wire suture to facilitate later identification at the
time of acute exploration of the wound . if nerve end can be easily
approximated they loosely sutured to prevent retraction during
interval of delayed repair
Secondary repair( after 2 weeks)-is indicated in heavily contaminated
wounds, if soft-tissue coverage is poor and requires flaps, if the
amount of nerve damage cannot be assessed early , or if the
diagnosis is initially missed.

63. TYPES OF NEURORRHAPHY
Epineurial repair- Is indicated for small nerves, for nerves with
only one or two fascicles, and for primary repair of a clean
laceration in a larger nerve.
Fascicular repair-especially in nerves with two to five large
fascicles or if epineurium constitutes a large part of the cross-
sectional area of the nerve.
Group fascicular repair-is similar in principle to fascicular
repair except that recognizable groups of fascicles are joined
instead of individual fascicles. This technique employed in
nerve grafting.

64. Epineurial Repair
With interrupted 7-0 or 8-0 nylon sutures

65. Fascicular Repair
With interrupted 9-0 or 10-0 nylon suture

66.  Mobilization of the nerve on both ends of the
lesion
 Positioning the joints in a favorable position
 Transposition
 Bone resection
 Nerve graft
 Nerve transplant/ Neurotization
 Non neural tubes (Vein/ Silicon)

67.  TYPE OF NERVE
 LEVEL OF INJURY
 WOUND CONDITION
 AGE OF PATIENT

68. • Poor prognosis in:-
- High lesion
- Mixed nerve
- Gap between nerve ends
- Adult
- Delayed repair
- Associated damage- vessel & tendon
- Surgery skill/experience/facility lack

69. TENDON TRANSFER FOR VARIOUS PEREPHERAL
NERVE INJURY
PREREQUISITES
WHEN
Radial nerve
when nerve repair performed and suitable recovery is anticipated
then tendon transfer should be delayed for 6month
Indication for early transfer
1.To act as a substitute during regrowth of nerve(as internal splints)
2.To act as helper as reinnervation proceeds
3.To intervene when the result of nerve repair is poor or irreparable
Median nerve and Ulner nerve
High nerve palsy 4 month
Low nerve palsy 3month

70. Tendon
transfer
Wrist
Extension
Thumb
Extension
Finger
Extension
Brand PT to ECRB PL to EPL FCR to EDC
Jones PT to ECRB PL to
EPL(rerouted)
FCR to EDC
Boyes PT to ECRB FDS of Ring
finger to
EPL&EIP
FDS of Long
finger to EDC
Tendon Transfer for Radial nerve Palsy
FCR to APL
&EPB
FCR is PREFFERED Over FCU
Difference between Brand and jones

72. FOR INTRINSICS PALSY
the long finger extensors are capable of extending the
interphalangeal joint if the metacarpophalangeal joints are
stabilized and cannot hyperextend
STATIC PROCEDURE DYNAMIC PROCEDURE
-Zancolli capsulodesis
-Fowler tenodesis -
Bouvier’s test:-If
extensor can extend
the pip with mcp
joint flexed -< 40
degree
fowler
transfer
EIP tendon
of index
and EDQP
Radial side of extersor
aponeurosis of each
finger
Riordan
transfer
PL and
EDQP
Radial side of extersor
aponeurosis of each
finger
Brand
transfer
ECRL or
ECRB with
graft
Radial side of extersor
aponeurosis of each
finger
Bunnel
transfer
FDS of the
ring finger
Radial side of extersor
aponeurosis of each

73. fowler riordian
brand

74. TENDON TRANSFER FOR MEDIAN AND
ULNAR NERVE PALSY
For thumb adduction
ROYLE
THOMPSON
TRANSFER
FDS of RING
finger divided
into 2 slips
To EPL and
Adductor
pollicis
BRANDS FDS of RING
finger
To adductor
pollicis
Boyes Brachioradialis To adductor
pollicis
SMITH ECRB To Adductor
pollicis

75. brands boyes
Royle
thompson

76. For thumb opposition
RIORDIAN RING FINGER
SUBLIMIS with
pulley over FCU
Epl ,Extensor
Apponeusosis,
APB
BRAND Ring finger
sublimis(2slips)
Proximal slip to
ulner side of mcp
joint distal slip to
APB and EPL
BURKHALTER
ET AL
EIP APB , MCP joint
capsule , EPL
CAMITZ PL APB

77. riodianbrands

78. For lower limb nerve palsy
OBER Anterior transfer of posterior tibial tendon
Other method for same procedure BARR

79. Split transfer of anterior tibial tendon

80. THANK YOU